Blood pressure management for secondary stroke prevention

Hypertension is the most important vascular risk factor for stroke; therefore, optimal blood pressure (BP) management is essential for the prevention of recurrent stroke; lowering BP was shown to reduce the risk of recurrent stroke by 25-30%. A recent meta-analysis showed that intensive BP lowering to levels <130/80 mmHg significantly reduced the risk of recurrent stroke compared to standard management with BP levels <140/90 mmHg. The benefit of intensive BP management is evident with regard to a reduced risk of intracranial hemorrhage. Therefore, clinical practice guidelines have established a target BP of <130/80 mmHg. However, the target BP needs to be individualized. A stepped-care approach for cautious BP lowering (usually to levels <140/90 mmHg) is preferred for patients with severe diseases of the major cerebral vessels, who have a high risk of recurrent ischemic stroke. In contrast, more aggressive BP lowering (to levels <120/80 mmHg) tends to benefit patients at high risk of intracranial hemorrhage. The selection of BP management strategies should be guided by the risk of recurrent ischemic and hemorrhagic strokes.